The Classification of Alcoholics Typology Theories From the 19 th Century to the Present

Alth ough alcoholism often is treat­ ed as a unitary disorder that can be described by a single disease label, ample evidence indicates that alcoholics differ in a wide variety of defining characteristics, such as drinking patterns, type of dependence, genetic predisposition, personality traits, and antecedent psychiatric disor­ ders. Recognition of this heterogeneity has led to attempts to develop alcohol­ ism typologies—that is, to classify groups of alcoholics according to defin­ ing characteristics—in order to better understand the etiology of alcoholism (i.e., the mechanisms leading to the disease), improve treatment, and ad­ vance the theoretical framework for alcoholism and its consequences. This article traces the clinical and scientific thinking about alcoholism typologies during the past 150 years. During this time, the history of typo­ logical thinking about alcoholics can be roughly divided into three periods: the prescientific period of clinical specula­ tion (1850–1940), the Jellinek era of review and synthesis (1941–1960), and the post­Jellinek period of increasingly sophisticated empirical research (1960– present). To the extent that ideas do not develop in a vacuum, this history provides an interesting example of how “invisible colleges” of like­minded thinkers are capable of advancing know­ ledge both as groups and individuals. The article also demonstrates that de­ spite the plethora of alcoholism ty­ pologies developed over time and the

llinek's landmark work have been derived mainly from empirical research data. Despite the wide variety of methodological approaches used, it appears that subtypes from all typologies developed since the 19th century can be classified into two major categories, the Apollonian and Dionysian

subtypes.KEY WORDS: AOD dependence; disorder classification; Jellinek typology; historical review; AOD use pattern; personality trait; AODR (alcohol and other drug related) disorder; comorbidity; etiology; AOD associated consequences; treatment research A lth ough alcoholism often is treat ed as a unitary disorder that can be described by a single disease label, ample evidence indicates that alcoholics differ n a wide variety of defining characteristics, such as drinking patterns, type of dependence, genetic predisposition, personality traits, and antecedent psychiatric disor ders.Recognition of this heterogeneity has led to attempts to develop alcohol ism typologies-that is, to classify groups of alcoholics according to defin ing characteristics-in order to better understand the etiology of alcoholism (i.e., the mechanisms leading to the disease), improve treatment, and ad vance the theoretical framework for alcoholism and its consequences.

This article traces the clinical and scientific thinking about alcoholism typologies during the past 150 years.During this time, the history of typo logical thinking about alcoholics can be roughly divided into three periods: the prescientific period of clinical specula tion , the Jellinek era of review and synthesis (1941)(1942)(1943)(1944)(1945)(1946)(1947)(1948)(1949)(1950)(1951)(1952)(1953)(1954)(1955)(1956)(1957)(1958)(1959)(1960), and the postJellinek period of increasingly sophisticated empirical research (1960present).To the extent

at ideas do not develop in a vacuum, t
is history provides an interesting example of how "invisible colleges" of likeminded thinkers are capable of advancing know ledge both as groups and individuals.The article also demonstrates that de spite the plethora of alcoholism ty pologies developed over time and the THOMAS F. BABOR, PH.D., M.P.H., is a professor and scientific director at the Alcohol Research Center, Depart ment of Psychiatry, University of Connecticut School of Medicine, Farmington, Connecticut.The writing of this paper was sup ported in part by National Institute on Alcohol Abuse and Alcoholism grant AA-P50-03510.variations among them, recurring traits in the drinkers' personalities appear to exist among the typologies, thereby allowing alcoholism subtypes to be separated into two major categories, the Apollonian and Dionysian subtypes.


WHY IS ALCOHOLISM TYPOLOGY IMPORTANT?

The urge to classify objects, ideas, and people into meaningful categories, or types, is a basic characteristic of human nature.When types are organized into a system according to definitional rules and practical applications, the classifi cation is called a typology.Although the tendency to classify people un doubtedly serves an important medical function (e.g., knowing that a particular patient with liver disease is an alcoholic may help clinicians more effectively manage that patient's disorder), the common propensity

reduce individ ual differences among
people to sim plistic stereotypes also can distort our perceptions of social reality.Alcoholics commonly have been associated with dysfunctional stereotypes, as evidenced by the variety of pejorative terms used in different languages to describe them.For example, vagabonds and homeless people with alcoholrelated problems have been referred to as "Bowery bums" and "Skid Row alcoholics."Other his toric, derogatory terms have included "sot," "wino," "rummy," and "lush."However, when looking beyond this oversimplification of popular culture to the history of medicine and psychiatry, it is clear that typologies based on the organization of clinical informat on through diagnostic classification, med ical nomenclature, and clinical sub typing have advanced our theoretical knowledge as well as the art of healing.


THE PRESCIENTIFIC PERIOD (1850-1940)

It would seem logical to begin a dis cussion of the history of typology with E.M. Jellinek's classic work on the different "species" of alcoholism (1960a,b), which is widely considered to be the first scientific alcoholism ty pology.Various historians, such as Mark Lender (1979), however, have pointed out that many 19th and 20th century "alienists" (i.e., physicians spe cializing in treating mental illnesses and addictive disorders) had a remark ably sophisticated appreciation of alco holism.Moreover, by studying the evolution of alcoholism typologies, current researchers can place Jellinek's ideas and subsequent thinking into a broader perspectiv .

The prescientific period of alcohol ism typologies roughly extends from William Carpenter's description in 1850 of different types of "oinoma nia," or wine mania (Carpenter 1850), to the psychoanalytic and character based theories of the 1930's.In many countries, alcoholism emerged as a major public health problem during the 19th century, just when medicine and psychiatry were developing as modern professional guilds.Thus, it is no coincidence that some of the lead ing physicians in countries such as France, England, Germany, and the United States devoted considerable attention to studying alcoholism.Ac cording to a review of the world alco hol literature, 39 classifications of alcoholics were developed between 18 0 and 1941 (Babor and Lauerman 1986).Most of these typologies were published by alienists in books and scholarly journals.

One of the earliest and most influ ential classifications was introduced in Carpenter's 1850 essay entitled On the Use and Abuse of Alcoholic Liquors in Health and Disease.Quoting exten sively from the Report of the Glasgow Lunatic Asylum published in 1842, Carpenter proposed three categories of oinomania: acute, periodic, and chronic.In the acute form, the desire to drink occurs suddenly, but the dis ease rarely progresses beyond irregu lar intoxication.The periodic form is characterized by a pattern of binge drinking that becomes progressively more severe and damaging.In the chronic form, the desire for alcoholic stimulation becomes an overwhelm ing preoccupation that precipitates constant alcohol consumption.

Twenty years after Carpenter's essay, several American physicians specializing in the care of alcoholics organized the Association for the Study of Inebriety, which promoted the dis ease concept of alcoholism, advocated the establishment of specialized hospi tals for inebriates, and supported the scientific study of i ebriety1 (Lender 1979).In 1876 the association estab lished the Quarterly Journal of Ine briety, which, over a period of 38 years, published numerous articles by leading physicians from the United States and abroad about the different forms of al coholism.Similar societies formed in England, under Norman Kerr's lead ership, and in France, under Valentin Jacques Magnan's direction.Through national and international meetings and a wide circulation of books and journals, the writings of these physicians and alienists became instrumental in defin ing the medical response to what was considered the disease of inebriety.

In 1893 Kerr, who also was an honorary member of the American association, published the influential textbook Inebriety and Narcomania, which divided inebriates into two groups, periodic and habitual (Kerr 1893).Periodic inebriety is character ized by intense drinking or craving for alcohol interspersed with periods of abstinence.For some alcoholics, the drinking periods are determined by internal cues, such as the onset of me nses in women.For others, external opportunities, such as a worker's pay day or sailor's shore leave, govern the periodicity of inebriety.Intervals of in tense nervous irritability and depres sion commonly precede the drinking periods.Periodic inebriety often takes the form of temporary insanity, in which the drinker's behavior is char acterized by mania, viole

e, or impul sive
criminal behavior.Habitual inebriety begins as a "vol untary indulgence" that eventually crosses the line between the physio logical and the pathological, resulting in a deterioration of physical and men tal abilities.Both habitual and period ic inebriety may manifest themselves in different ways, leading to a further classification of inebriates as social and unsocial.Social inebriates drink openly with other drinkers, whereas un social, or solitary, inebriates shun the company of others and tend to drink se cretly, often because of "neurasthenia" (i.e., exhaustion of the nervous system).


G L O S S A R Y

In 1911 Thomas Crothers, cofounder of the Association for the Study of In ebriety, presented another alcoholism typology in his book Inebriety: A Clin ical Treatise on the Etiology, Sympto mology, Neurosis, Psychosis and Treatment.His classification, based on years of clinical experience, resembled Kerr's classification but included three types: the continuous drinker, the explosive inebriate, and the periodic drinker (Crothers 1911).The first type, the continuous drinker, is character ized by a lengthy preliminary period of moderate drinking leading to the "gradual growth and cultivation of the drinking impulse" (p.40).The explo sive inebriate uses alcohol infrequently, usually in response to some precipi tating cause, and becomes extremely intoxicated.The third type, the periodic drinker, includes several subcategories, such as dipsomaniacs, who are "ma ked by an insane overpowering impulse which is a veritable mania" (p.41).In addition, the periodic drinker is influ enced by environmental factors, men tal stress, and physical conditions.The abrupt onset and cessation of drinking resemble epilepsy and other convul sive disorders, "with distinct physical causes and conditions not under the control of the will" (p.71).Crothers proposed that emotional factors can be both the cause and consequence of periodic drinking, with intense excite ment or depression frequently reced ing intoxication and "melancholia" and suicidal impulses often following it.

In discussing the general causes and conditions favoring inebriety, Crothers (1911) also classified alcoholism as either acquired or hereditary.People with acquired inebriety often have histories of physical disorders, partic ularly dyspepsia (i.e., indigestion), bad nutrition, and exhaustion from unhy gienic living conditions or stressful work environments.Conversely, hered itary causes include constitutional con ditions, such as distinct neurotic and psychopathic disorders that often are traceable to ancestors.

As in the United States and England, prominent French alienists during the late 19th century also began writing about the increasing numbers of alco holics found in the nation's insane asylums.In his book, Hérédité et Alcoolisme, Paul Maurice LeGrain (1889) incorporated the major psychi atric theories of the day into a com prehensive alcoholism typology that included three types of alcoholics: morally insane alcoholics, weakwilled alcoholics, and dipsomaniacs.The first type, morally insane alcoholics, have a poor y developed moral sense and thus do everything in excess.Their frequent intoxication often results in accidents and violence.The second type, weakwilled alcoholics, have an adequate moral sense but lack will power.These alcoholics drink either because they like the taste of alcohol ("par gout") or by habit ("par ntraine ment").The third type, dipsomaniacs, are impulsive drinkers whose will power dissolves in alcohol.In addition, all three types suffer from defective mental states brought on primarily by inherited mental degeneracy, which was thought to be cumulative in cer tain families.

A decade later, physicians Henri Triboulet and Félix Mathieu (1900) distinguished between dipsomaniacs, hereditary regular alcoholics, and non hereditary habitual drinkers, suggesting that the latter respond well to simple advice at an early stage and to voluntary commitment to a special asylum at a later stage.

A common theme in the French medical literature of the time was the description of a less socially disruptive form of alcoholism epitomized by Dro mard's (1902) term "les alcoolisés non alcooliques" (chronically alcoholized nonalcoholics).These regular drinkers develop progressive habituation to al cohol's toxic effects, followed by an irresistible need to drink.Morning drinking relieves mild withdrawal symptoms, and the person's life be comes centered around the use of small doses of alcohol throughout the day.Eventually alcohol's cumulative effects lead to major medical complications and organic brain disorders.

In one of the first books devoted exclusively to alcoholic subtypes, En glish physician Hugh Wingfield ex plored the nature, causes, and treatment of alcoholic subtypes in his 1919 treatise on The Forms of Alcoholism and Their Treatment.Like his prede cessors, Wingfield collected much of the information from his own experi ences with patients.He proposed four main varieties of alcoholics: pseu dodipsomaniacs, chronic sober alco holics chronic inebriate alcoholics, and true dipsomaniacs (Wingfield 1919).Pseudodipsomaniacs drink in great excess, usually in bouts lasting a week or more, as a result of craving induced by an initial drink of alcohol.Chronic sober alcoholics are characterized by daily drinking over relatively long periods of time.They are infrequently intoxicated and crave alcohol only if it is partially or completely withheld.Chronic inebriate alcoholics drink regularly and are almost always in toxicated.Finally, true dipsomaniacs experience spontaneous craving and engage in short drinking bouts.

In questioning the value of "com pulsory restraint in a retreat for long periods," Wingfield (1919, p. 42) proposed specific treatments for dif ferent types of alcoholics.For pseudo dipsomaniacs and true dipsomaniacs, he recommended administering small doses of apomorphine to provide tem porary relief of craving and morphia to trea intense depression.Chronic alco holics should first be given diminishing doses of alcohol to reduce the risk of delirium tremens before being treated with drugs and "suggestion."The drug of choice was atropine, given in con junction with strychnine.Suggestion, especially under light hypnosis, was designed to "lessen the risk of relapse long after treatment is ended" (p.68).According to Wingfield, suggestion reduces "haunting ideas of drink," in creases the patient's will power, and sometimes brings to light repressed memories, "effecting a real cure there by" (pp.69-70).

Wingfield's reference to repressed memories indicates the growing influ ence of psychoanalytic theory, which argued that alcoholism was merely the symptom of an underlying neurosis.Psychoanalyst Robert Knight (1938) developed these ideas further, propos ing three types of alcoholics: essential alcoholics, reactive alcoholics, and symptomatic rinkers.The first type, essential alcoholics, are characterized as psychopaths with an oral fixation and a conflict between feminine pas sivity and masculine strivings.They experience an early onset of alcohol problems and do not perform well in school or at work.In contrast, reactive alcoholics usually begin drinking in response to a precipitating event and respond better to treatment, in part because they are better adjusted ini tially.The third type, symptomatic drinkers, experience prominent neu rotic or psychotic symptoms that are responsible for their drinking.

In contrast, typology theory in Ger many was influenced not so much by psychoanalytic ideas as by constitu tional theories that expla

ed drinking behavior based on physiqu
and tem perament.Ernest Kretschmer (1924), for example, proposed two groups of chronic alcoholics: a cyclothymic type whose drinking results from a pliable, gregarious disposition, and a schizoid type, who uses alcohol to relieve in ternal stress.With the further develop ment of constitutional theories during the 1930's, typological formulations were used to justify the involuntary surgical sterilization and removal of "hereditary" alcoholics to concentra tion cam s during the height of the Nazi era (Babor and Lauerman 1986).


The Significance of Early Typologies

As this brief review demonstrates, the early typologies were unsystematic, based primarily on clinical observation and anecdotal evidence, and lacked an empirical foundation, thus leading to a confusing array of concepts and nomenclature.Moreover, they did not lead to the development of theories ex plaining the etiology, manifestations, and consequences of alcoholism, be cause they did not propose verification procedures to test assumptions and pre dict behavior.

Despite these shortcomings, the early attempts to differentiate and clas sify alcoholics had a positive influence on the development of alcohol studies.For

xample, they led
o the identi fication of important defining charac teristics of alcoholic subtypes, such as family history, psychopathology, drinking patterns, personality factors, and physical consequences.These early typologies also introduced the concept of treatment matching; 2 in spired some crude attempts at empiri cal investigation; and suggested that the etiology, symptomatology, and natural history of alcoholism were complex phenomena.Finally, they set the stage for the development of more sophisticated theories, such as those developed by Jellinek.


THE JELLINEK ERA

In 1941 psychiatrist Karl Bowman and biometrist E.M. Jellinek wrote a com prehensive review of the alcoholism treatment literature for the newly estab lished Quarterly Journal of Studies on Alcohol (Bowman and Jellinek 1941).Their review, "Alcohol Addiction and Its Treatment," contained a masterful integration of 24 typological formula tions that had appeared in the world alcohol literature prior to 1940 and which formed the basis for the most detailed alcoholism typology to date.Using a hierarchical classification ap proach modeled after the way botanists identify genera and species, this typol ogy began with two broad categories defined by the pattern of drinking (i.e., steady nd intermittent, which was further differentiated into periodic and irregular).These groups were further subdivided according to the etiology of the disease into subtypes resulting from internal (i.e., endogenous) or ex ternal (i.e., exogenous) causes, result ing in four major categories-primary alcoholics, steady endogenous symp tomatic drinker , intermittent endo genous symptomatic drinkers, and stammtisch drinkers-and several minor categories that encompassed the subtypes identified by previous theorists.The four major subtypes ere described as follows:

• Primary or "true" alcoholics are characterized by their immediate liking for alcohol's effects, the rapid development of an uncontrollable need for alcohol, and their inability to abstain.In contrast, alcohol de pendence in the remaining subtypes, which collectively are called sec ondary addicts, develops in the course of prolonged drinking.

• In steady endogenous symptomatic drinkers, alcoholism is secondary to a major psychiatric disorder.Subtypes of this cat gory include schizoid, schizophrenic, and syph ilitic alcoholics.

• Intermittent endogenous sympto matic drinkers are distinguished primarily by their periodic drink ing pattern but also develop alco holism secondary to a psychiatric disorder.For example, epileptic and epileptoid drinkers are driven to wild drinking bouts by a seizure like brain disorder.Similarly, manic depressive disorder is thought to produce periodic excessive drink ing.For socalled hypothetical true dipsomaniacs, periodic drinking is symptomatic of an underlying or ganic disease.

• In socalled stammtisch drinkers, alcoholism is precipitated by ex ogenous causes.These people, who can be further subdivided into social compensating, easygoing, and pro motional alcoholics, use alcohol on a daily basis around the table ("stamm tisch") set aside for the regular cus tomers at a cafe, bar, or restaurant.

Despite the historical scope and conceptual depth of the Bowman and Jellinek synthesis of typological theory, their classification system inspired vir tually no research and received little attention in the subsequent alcohol lit erature.Nevertheless, two decades later Jellinek (1960b) used his familiarity with the world typology literature to make typology theory the centerpiece of his book The Disease Concept of Al coholism.Based on etiologic elements, alcoholic process elements (e.g., level of tolerance or loss of control), and damage elements, Jellinek (1960a,b) proposed five types, or species, of al coholism: alpha, beta, gamma, delta, and epsilon (table 1).Jellinek consid ered only two of the species-gamma and delta alcoholics-to exhibit suffi cient evidence of alcohol dependence to represent true disease entities.These two types differ primarily in terms of etiologic factors (i.e., gamma alcoholics drink because of psychological vulner ability, whereas delta alcoholics drink because of social and economic influ ences) and alcoholic process elements (e.g., gamma alcoholics exhibit loss of control, whereas delta alcoholics ex hibit an inability to abstain from alco hol consumption).

Jellinek's new typology still closely resembled the earlier BowmanJellinek synthesis.Compared with the older classification system, the 1960 typology c mbined the two groups of symp tomatic drinkers into one group, the gamma alcoholics; renamed the primary addicts (sometimes called true dipso maniacs) as epsilon alcoholics; and de signated the more severe stammtisch drinkers as delta alcoholics.Although the alpha and beta subtypes were im plicit in the 1941 classification, it was not until Jellinek added a biobehavioral concept of dependence to the theory that these alcoholism subtypes, which were not characterized by physical dependence, assumed a prominent place in typological classification.

With the tremendous popularity of Jellinek's (1960b) book on the disease concept, the gammadelta typology became the most widely accepted sys tem for differentiating among types of alcoholics, perhaps because it was imbedded in a credible and compre hensive theory of alcoholism that rep resented the cumulative contributions of scores of clinicians and scholars.Drawing from the clinical literature published in France, England, Germany, and the United States, and from the growing body of experimental research conducted in the 1940's and 1950's, Jellinek's theory became a standard fixture in the vocabulary

alcohol studies, les
for its originality than for its ability to organize complex clinical phenomena into meaningful categories.

Despite the general acceptance of Jellinek's theory, however, the typol ogy stimulated little empirical research, nor did it inspire attempts to develop comprehensive diagnostic measure ments or to match subtypes to specific therapeutic interventions (Babor and Dolinsky 1988).Nevertheless, Jellinek's work provided typology research with a new impetus that ushered in the post Jellinek era of typology development.


THE POSTJELLINEK ERA

Until the 1960's, typology theoryincluding Jellinek's work-was guided primarily by armchair intuition and clin ical observation.With the development of better measurement techniques and research methods, however, empirical research on typologies gained momen tum.For example, in the a priori com parative approach, researchers classify two or more groups of alcoholics on the basis of defining, or a priori, cri teria (e.g., gender, family history of alco holism, or coexisting psychopathology) and then compare these groups on hy pothetical correlates, such as age of on set, rapidity of symptom development, and severity of dependence.Several studies using this approach indicated that alcoholic subtypes defined by sin gle dimensions could indeed be differ entiated in predictable ways on a variety of other dimensions (see Babor and Dolinsky 1988).For example, research using gender as a defining typological criterion showed that compared with men, women underwent a later onset of alcoholism and a more rapid course of symptom development and were more likely to experience depression prior to becoming alcohol dependent (Del Boca 1994).The study also dem onstrated, however, that various typo logical criteria other than gendersuch as psychopathology, sexlinked physiological characteristics, and so cially defi ed gender roles-could better explain these differences.

A history of alcoholism in first degree relatives also has been used frequently as a typological criterion in the postJellinek period.Several stud ies found that alcoholics with positive family histories experienced an earlier onset of dependence symptoms, more social and personal problems connected wi h their drinking, a rapid course of symptom development, and more se vere alcohol dependence than alco holics with negative family histories (Frances et al. 1980;Penick et al. 1978).

Other studies compared alcoholics with and without coexistent psychopath ologies.These analyses found, for ex ample, that alcoholics with antisocial personality disorder (ASPD) began drinking earlier, progressed to prob lem drinking more rapidly, and

pe rienced more complications from their drinking than al
oholics without ASPD (Hesselbrock et al. 1984).

These examples demonstrate that although various typologies use differ ent defining criteria, they often identify similar subgroups of alcoholics.For example, typologies differentiating be tween late onset and early onset sub types (BuydensBranchey et al. 1989;Parrella and Filstead 1988) closely re semble alcoholic subtypes defined by the presence or absence of familial al coholism, antisocial behavior, or psy chiatric disorders.


Examples of Typologies Developed in the PostJellinek Era

Beginning in the 1970's, typological theorists began to incorporate greater complexity into their models, not only by postulating subtypes that encompass multiple defining characteristics but also by deriving the typological char acteristics from empirical data.Exam ples of these newer, multidimensional typologies include Morey and Skin ner's (1986) hybrid model, Cloninger's (1987) neurobiological learning model, Zucker's (1987) developmental model, and Babor and colleagues' (1992) vulnerability and severity theory, all of which are summarized below.Morey and Skinner (1986) adminis tered a battery of psychological tests to 725 subjects seeking treatment for alco hol abuse.Using a complicated statis tical technique called cluster analysis, which searches for groups of people with similar characteristics, the re searchers identif ed three types of drinkers: early stage problem drinkers, affiliative drinkers, and schizoid drinkers.The first type, early stage problem drinkers, includes people with alcoholrelated health and social prob lems who have not developed major symptoms of alcohol dependence.The second type, affiliative drinkers, are more socially oriented, tend to drink on a daily basis, and demonstrate moder ate alcohol dependence.In contrast, schizoid drinkers are socially isolated, drink binges, and exhibit the most severe dependence symptoms.

Based on prospective adoption stud ies, Cloninger (1987) and colleagues (1981) proposed a neurobiological learning model of alcoholism that dis tinguishes two genetic subtypes, termed type I ("milieu limited") and type II ("male limited").Type I alcoholics are thought to experience a later onset of alcohol problems, develop psycho logical rather than physical dependence, and report feelings of guilt about their alcohol use.In contrast, type II alco holics manifest alcohol problems at an early age, exhibit spontaneous alcohol seeking behavior, and are socially disruptive when drinking.Heritable personality characteristics, such as novelty seeking, may account for these different types of alcoholism.The age o onset (early versus late) provides a convenient way to classify patients who resemble type I and type II alcoholics (von Knorring et al. 1985;Buydens Branchey et al. 1989).(For more in formation o this typology, see the article by Cloninger and colleagues, Zucker's (1987) developmental model, which was derived in part from a longitudinal study of 102 al coholic men, postulates four types of alcoholism-antisocial, d velopmen tally cumulative, negative affect, and developmentally limited-with the following characteristics:

• Antisocial alcoholism is charac terized by the early onset of b th alcoholrelated problems and anti social behavior.This alcoholism type is thought to have a genetic basis and a poor prognosis.

• In developmentally cumulative alcoholism, drinking initially is limited and induced by cultural influences.Over the life course, however, the cumulative alcohol consumption is sufficient to pro duce alcohol dependence.

• Negativeaffect alcoholism, which is considered to occur primarily in women, is characterized by the use of alcohol for mood regulation and to enhance social relationships.

• Developmentally limited alcohol ism is characterized by frequent heavy drinking in late adolescence that tends to remit to social drink ing after the individual successfully assumes adult responsibilities, such as a career and a family.Babor and colleagues (1992) based their typology on the assumption that the heterogeneity among alcoholics is attributable to a complex interaction among genetic, biological, psycholog ical, and sociocultural factors.Con sequently, no single characteristic distinguishes alcoholics from non alcoholics, and separate homoge neous subtypes differ by more than just one defining characteristic.The researchers therefore reviewed the alcoholism typology literature since the mid19th century to identify de fining typological characteristics that combined could accurately describe alcoholic subtypes.Using cluster ana lysis, the investigators identified two types of alcoholics who differ consis tently across 17 defining characteris tics, including age of onset, severity of dependence, and family history of alcoholism.One group, designated type A alcoholics, is characterized by later onset of alcoholism, fewer child hood risk factors (e.g., conduct dis order and attention deficit disorder), less severe alcohol dependence, fewer al oholrelated problems (e.g., arrests or job loss), and less psychopathology.The other group, termed type B alco holics, is characterized by childhood risk factors, a family history of alco holism, early onset of alcoholrelated problems, greater severity of depen dence, multiple drug use, a more chronic treatment history despite their younger age, greater psychopathology, and more life stress.The two types also differ with respect to treatment outcome, with type B alcoholics more likely to relapse to heavy drinking.

In general, typology research during the postJellinek era has been charac terized by the systematic study of clin ical populations using a variety of empirical techniques, including psy chological testing, clinical interviews, and analysis of biological markers.Combining these techniques with in novative research designs-such as genetic epidemiology; prospective, longitudinal monitoring; and post treatment followup evaluationsmodern typology research has led to an improved conceptual understand ing of the complex array of variables characterizing the diversity among al coholics.Moreover, as typologies based on single defining characteristics (e.g., gender or family history of alcoholism) have given way to multidimensional classification schemes, researchers for the first time have conducted repli cation studies.

Despite these

gnificant improve ments in recent typology rese
rch, the field still faces some challenging issues.For example, perhaps because of the differences in measurement techniques and methodological approaches, typol ogy researchers have not always recog nized the similarities between their own work and that of other investigators.And although some theories are likely to endure longer than others, a more fundamental question remains concern ing the utility of typologies for theory development and clinical practice.This means that, for example, type A alcoholics are basical ly the same as milieulimited or delta alcoholics, with some differences be tween these types resulting from the different methods and defining cri teria used to establish the typologies.

The ApollonianDionysian distinc tion has been used to summarize the commonalities among alcoholic sub types.Greek and Roman mythology attributes the characteristics of con templation, intellect, artistic creativity, and selfrestraint to the god Apollo.As suggested in the subtypes grouped under this designation, when alcohol depen dence develops in such an in ividual, typically after years of socially ap proved heavy drinking, it presents in a more benign form.Consequently, Apollonian subtypes include alcoholics who are characterized by later onset, a slower disease course, fewer complica tions, less psychological impairment, and a better prognosis.In contrast, the god Dionysius was known for his drunken revelry, sexual abandonment, and physical aggression.When alco hol dependence develops in this type of personality, it can be identified by the subtype characteristics of patho logical drinking and drunken comport ment.Thus, Dionysian subtypes of alcoholics are characterized by early onset, more severe symptomatology, greater psychological vulnerability, and more personality disturbance.

It is interesting to note that the sub types summarized in table 2 have been identified through armchair intuition as well as by comparative research and empirical clustering techniques.To the extent that different methods have identified subtypes with similar features, this provides strong evidence for the cumulative wisdom of the past as well as the progress mad in recent years.

Confirmation of the hypothesis that only two broad categories of alcoholics exist would represent an important breakthrough for theory development and treatment matching.For example, research on the etiology of alcoholism might be informed by the possibility that two different paths may lead to alcohol dependence-one originating primarily in environmental influence and the other in genetic and personality factors.Treatment matching and pa tient placement also might profit from this knowledge, provided that differ ent therapeutic approaches and treat ment settings prove to be differentially effective with different types of alco holics.Despite oneandahalf cen turies of progress and a remarkable acceleration of interest in alcohol research in the past two decades, these critical issues continue to define the challenge as well as the promise of typology theory.■

Table 2
2
Chronological Compendium of Typological Theories Organized According to Apollonian and Dionysian Characteristics
Theorist Carpenter LeGrain Kerr Triboulet and Mathieu Crothers Wingfield Kretschmer Knight Bowman and Jellinek Jel